Roger Anderson, Ph.D. Professor Health Services Research Core Penn State Cancer Institute

1. Patterns of Care in Breast Cancer: On Care Coordination in Underserved Populations and the Use of Health Claims Data. Roger Anderson, Ph.D. Professor Health Services Research Core Penn State Cancer Institute Penn State Hershey Medical College Research Roundtable Appalachia Community Cancer Network September 28, 2007 Hershey, PA

2. Research team • PSU: Fabian Camacho, M.S. • Gary Chase, Ph.D. • WFU: Wenke Hwang, Ph.D. • Kristie Long-Foley, Ph.D. • Duke: Gretchen Kimmick, M.D. • CCR: Karen Knight • NCHS: Tim Whitmire, Ph.D.

3. North Eastern North CarolinaCounties Age adjusted Breast Cancer Death rate per 100,000 Source, North Carolina Cancer Registry, 2005,; SEER, National Cancer Institute, 2005

4. Objectives • Describe assembly of linked-Medicaid- North Carolina cancer registry data. • Describe the use of this dataset to identify unmet needs in cancer prevention and control • Discuss applicability to ACCN • Discuss health services research implications

5. Medicaid and Rural Health • Medicaid is an important source of health insurance coverage for both rural residents and rural providers. • Rural residents are more likely to live in poverty than urban residents, and are less likely to have employer sponsored health insurance coverage. • Rural residents are more likely to be covered by Medicaid than are urban residents.

6. Percent Residents with Medicaid Coverage During the Past Year in Urban and Rural Counties. CPS, 2004-2005 State Rural Urban Kentucky 17.4 12.1 Maryland 16.8 8.6 New York 17.4 18.3 Ohio 11.2 12.3 Pennsylvania 12.0 11.3 Virginia 11.5 6.9 West Virginia 18.2 11.3

7. NC Tumor Registry + Incident cases Clinical data 1st course of Tx (FORDS) Hospital Registrars Other facilities Merged data CDC proficiency testing NC Medicaid Claims All medical services* (ICD-9/10, CPT) Pharmacy (NDC) [monthly eligibility] [no clinical data] * Variable by state North Carolina Project

8. Database 1998-99 Medicaid Claims for North Carolina. • N=1,401 female breast cancer (single primary, all stages, 20% all cases) Caveats of Medicaid claims: • Managed care organizations omitted • Dual eligibility - Medicare • Continuous enrollment - pre-and-post diagnosis. • Bundling of claims (date/services) • Completeness of claims (unbilled services?)

9. Data Sources Caveats of Hospital Registry data: • First course of treatment may be defined as 4-months post diagnosis. • Treatment in physician offices may go unreported. • Out-of state services often missing • May exclude VHA cases • Comorbidity – added in 2003 • Non-registry (mid-size) hospitals lower quality data

10. Data Sources Caveats of Medicaid data: • 9- 12 months of continuous eligibility is generally needed. • Medicare files m,ay be needed for dually insured. • Policies on covered services may vary by state.

11. Methods • Test Population (1998-99 cases): 1,401 cases single primary breast cancer in NC registry years 1998 - 1999. • Test sample: 845 (60%) cases enrolled in Medicaid 1 month prior and 12 months post registry date of diagnosis • Approach: • 1) Assume registry data is accurate if treatment is listed as provided (not missing or indeterminate). • 2) Else, replace data with Medicaid claims (if discordant). • 3) Validate by performing record review on sample of cases.

12. Accuracy of Radiation data in BCS sample BCS sample Sensitivity Specificity Registry 84% 100% Claims 95% 93% Combined97% 98%

13. Table 3. Adjusted Odds of Registry Codes for Radiation and Chemotherapy when Medicaid Claims are Present CCR Agreement on Chemotherapy CCR Agreement on Radiation Sample N # with radiation claims: 279 # with chemotherapy claims: 236 Caucasian vs Other 0.89 (0.48, 1.66) 0.57 (0.31, 1.05) Dually Eligible No vs Yes 0.72 (0.37,1.40) 2.33 (1.24, 4.41) N/A vs 5 + cm 1.10 (0.36,3.31) 0.62 (0.17,2.35) 0-1 cm vs 5+ cm 2.39 (0.67, 8.54) 0.27 (0.05,1.65) Tumor Size 1-2 cm vs 5+ cm 1.71 (0.60, 4.84) 0.65 (0.18,2.27) 2-5 cm vs 5+ cm 0.74 (0.29,1.94) 0.35 (0.12,1.09) Lymph Nodes Removed 1.15 (0.58,2.25) 0.94 (0.45,1.95) Class of Case 1 or 2 present 4 5.27 (0.54,51.14) 7.74 (1.22,49.09) Registry Facility 0.11 (0.037, 0.35) 0.43 (0.18,1.05) 7.77 (2.80,21.58) 4.31 (2.08,8.94) Days to first claims since dx (Rad column, Chem column) 0.989 (0.985,0.993) 0.994 (0.988, 0.998)

14. Examples of Application to Answer Patterns of Care • And Outcomes Research Questions

15. Table 1. Correlates of Under Use of Radiation Treatment with BCS in North Carolina Medicaid Correlates of Under Use of Radiation Treatment with BCS in North Carolina Medicaid 1. Based on presence of any paid claims from nursing home (location of service=T), home healthcare services (Q) or skilled nursing facility (cos = 35,36). 2. Tertile distribution of number of beds reported by American Hospital Directory. 3. Based on patient discharges reported by American Hospital Directory 4. Median split of all breast cancer cases with Medicaid enrollment.

16. Table 3. Interaction Graph showing unadjusted proportions of Radiation Treatment in BCS patients by Metropolitan Status and Hospital Size

17. 1.00 0.75 0.50 0.25 0.00 0 500 1000 1500 2000 2500 Days since diagnosis Radiation No Radiation Kaplan-Meier Survival Curves of All-Cause Mortality by Radiotherapy Treatment

18. Cormorbidity among Women with Breast Cancer in NC Medicaid • N= 1,401 • ● 55 % had at least one other comorbid condition defined in Charlson comorbidity index • ● Among those with comorbidity, > 50% had multiple conditions. • ● The top three comorbid conditions were: • Diabetes (26%) • Congestive heart failure (18%), • Chronic pulmonary disease (11%).

19. North Carolina Medicaid enrollees with a diagnosis of diabetes with and without breast cancer: Medication Possession Ratio: diabetes medicines/ insulin products 12 month days supply mean days (SD)____________________________________________________ Women without cancer 300 (19) With breast cancer 205 (95)

20. Hormone Medication Persistence. NC Medicaid Breast CancerMonali Bhosle OSU Cumulative nonpersistence rate based on number with + ER status who started therapy. No significant association between race and medication persistence adjusting for a type of index therapy and other confounders (hazard ratio (SE) [95%CI]: 1.13 (0.30) [0.68-1.89].

21. Current Multi-Site Study • ● CDC Patterns of Care Study (Breast and • Prostate CA) • 7 States + PSU • Registry data + CMS • Centralized data processing (5 sites). Pooled data analysis • Model • NCCN guideline concordant care • Health system and patient characteristics • Care coordination

22. Proposal • ● Develop set of cancer prevention and control outcomes consistent with CDC pattern of care studies. • ● Seek funding to link 7 ACCN States Registry data to Medicaid/Medicare. • ● PSCI Health Services Research Core serve as Data and Support Center to provide: • IRB templates • Data acquisition and linkage • Archive • Analysis support